So there’s this thing in Quebec which I’m sure my Canadian readers have heard of and maybe also a few of my American readers, which involves the Quebec government devising some legislation called the Charter of Quebec Values. I have to say “charters” and “values” are nice happy positive words, and Quebec is filled with deliciously cheesy poutine, hockey, maple syrup, and those devilishly sexy Québécois men, so what’s there not to like (except for les Habs, boo, hiss!)?

The thing is, this Charter of Quebec Values wants to ban wearing obvious religious symbols for all public employees, including nurses and other health care professionals. This, I have to say, has ABSOLUTELY NOTHING TO DO with some nice Ladies of Muslim persuasion cheekily wearing hijab in broad daylight in Montreal and everything.

From the Government of Quebec website. Top: acceptable. Bottom: Va te faire foutre (You can Google Translate that too.)

(Just so you know, American readers, I must also officially tell you is NOT racist, and the fact the proposed legislation targets Quebecers with brown skin is merely, um, an unfortunate coincidence. We say this because the Quebec government is acting from the purest, noblest of intentions. This is a Fact, because the Quebec government has told us so. (You can Google translate it or something.) It is well-known that the separatist, ruling Parti Québécois has long been offended by clerical collars, Jewish kippahs, wimples and garish Roman Catholic crucifixes. This is also a Fact, which you can also Google.)

The proposed charter will affect health care professionals, including nurses. My question, then, does the wearing of religious symbols or associated clothing have any place in the provision of health care? Should nurses don hijab on the hjob?

Before you run off to start raving, maybe you should consider a few things. First, banning headscarves (or whatever) has a distinct element of authoritarian nastiness about it. Should the nursing profession be that coercive? There’s probably no getting around the fact that if the legislation is passed, it will be nurses enforcing the ban against other nurses.* (The irony of having the Quebec government telling Muslim women how to dress, partly, it is argued, to ensure gender equality, is beyond these guys.)

Another thing: nurses have a long history of wearing weird things on their heads. It’s safe to say that if you look over the course of the history of nursing, no crazy headgear has been the exception, not the rule.

Like this:

Or this:

Or this:

Which reminds me: some of you might say, oh it completely different! it’s a religious thing! Muslims shouldn’t be pushing their faith in our faces!

Well, there’s this:

+

And this:

But not this? (Love this ad, by the way. It was created in response to the proposed Quebec law..)

So if you’re offended by women in hijab but not by Catholic nursing sisters, what’s the difference? Do you really believe the hijab (or any other piece of religious accoutrement) sucks out the nursing from the nurse?

So dear readers, hijab for nurses and other health care professionals, yes or no?

____________

*The Quebec nurses union, FIQ, has courageously taken the position of taking no position at all. In other words, the union won’t defend members running afoul of this law. I’m pro-union, but holy Sam Gompers, sometimes their leadership are dumb as stumps.

This story has been bouncing around the Canadian media since last May. Camille Parent, the son of a nursing home resident, set up a hidden camera in his mother’s room for four days after she (the nursing home claimed) was assaulted by another patient. The results were appalling. Watch here:

The nursing home immediately fired the four staff members seen in the video; the contract of the director was not renewed. The police, however, have decided not to prosecute; the legal case for pressing assault charges, they said, is a lot narrower than what you or me would consider abusive.

That the standards in this nursing home are so abysmally lax is nearly beyond comprehension. Just after this particular facility opened about ten years ago, I accompanied a friend on a tour of the place. I remember thinking at the time, “If I ever need supportive care, this is where I want to go.” They had an exemplary care model, good staff/patient ratios, and a well-designed environment.

For me, it was interesting the reflex reaction of the director was to axe the employees involved, because as we all know, the best way to address issues in any health care institution is to fire employees.

Voilà! Problem fixed!

The problem with this hypothesis (i.e. the Rogue Employee Theory) is that four employees in four days with one patient displayed behaviours that were, um, sub-optimal.

No, sorry. You can’t just blame the employees, though they need to be accountable for their actions. The administration of the nursing home needs to take some (most?) of the responsibility for permitting an institutional culture where waving faeces-soiled wash cloths in patients’ faces, and canoodling in patients’ rooms is acceptable behaviour.

Our Mission

St. Joseph’s at Fleming is a non-profit long term care health provider committed to excellence in the delivery of quality care and services to persons of all faiths. Continuing the legacy of the Sisters of St. Joseph of Peterborough, the Home takes pride in a model of care distinguished by compassion, dignity, respect and integrity.

Our Vision

Leader and valued partner in long term care through the use of innovation and best practices in living, learning and caring.

Our Core Values

LivingSt. Joseph’s at Fleming is committed to creating a healthy living and working environment that:[. . . ]

• Treats people with fairness and social justice

[. . . ]

LearningSt. Joseph’s at Fleming is committed to creating a unique learning environment for Residents, families, staff, volunteers and students that:

• Promotes innovation and best practices

[. . . ]

• Develops leadership and promotes teamwork

CaringSt. Joseph’s at Fleming is committed to providing exemplary physical, emotional and spiritual care to our Residents, their families, staff and volunteers. Our philosophy of care:

• Engenders trust, healing and wholeness • Integrates best practices and innovative solutions• Promotes individuality as well as personal and spiritual growth • Is characterized by compassion, respect, dignity and the sanctity of life

All of which is very good, anodyne and even commonplace, and I am sure it looks very nice hanging in the front lobby. It’s pretty easy to point out where the nursing home and its employees betrayed its own mission and values, so obviously, it’s not enough. If I were the provincial investigator looking at this nursing home, my very first question would be, “How are your values exemplified in how you provide care?” In other words, how do you ensure institutional values — all those warm fuzzies listed above — align with the personal values of the staff? (Clearly, they didn’t in this case.) And also: what policies and procedures do you have in place that address abuse? What education do you give staff around patient abuse, or the issues that surround the care of cognitively impaired patients? How do you evaluate the effectiveness of that education? How do those in leadership positions role model behaviour? What processes do you have in place to care for demented patients? How do front line staff participate in the development of such processes? How do you reward/celebrate excellence? And so on.

I’m guessing the answers to most of such questions would be “a little” or “not at all.”

So who should be held accountable?

The front line staff?

Yes.

The leaders, the managers and the administrators?

Yes. Probably more so.

So what do you think? Who is to blame? Staff or administration or both?

To everyone who emailed and texted and Tweeted, thanks. Everything is hunky anddory. I’m not dead, ok? Let’s get that out of the way. Nor am I afflicted with a Chronic Debilitating Illness, unless you count members of my family. (That would be the topic of long separate blog post + extended psychotherapy.)

So what happened? Much to my surprise and amazement (and frank gratitude if truth be known) I got a new job about this time last year. A job with a very steep learning curve and a fairly cool boss with an alphabet soup of letters after her name and about as far away from Emergency nursing as you can imagine without leaving the hospital.

It is true, friends.

I have walked away from the front line.

I have drunk the mystical Kool-Aid.

I am Management.

But not real Management. I don’t actually manage anyone. I make up PowerPoints (ugh), give talks, and do research. I write policies. I have projects. I educate patients and staff. I occasionally make recommendations to Important People many steps above my pay grade, When I do speak, the senior administration actually pays attention and sometimes will do this or that based on the words flowing out of my mouth. This is a bit of a revelation for a front-line nurse used to managers halfheartedly and reluctantly paying attention. OK, not really paying attention at all.

Nurse K once suggested to me that my ambitions for real management were probably misplaced. Having observed front-line managers from the other side up close for the past year, I have to agree. Being a front-line manager truly and deeply sucks. It’s far worse than being a charge nurse. (I say this as an embittered former old charge nurse, remember.) Awesome amounts of responsibility and no actual power. And navigating the snakepit which is hospital politics. And the risk of being walked off the property at will. Great job, right?

So first lesson: I think I dodged a bullet there. I really don’t want to be a manager.

Second lesson: This is the first job where I use all of the skills I have acquired as a nurse in a meaningful and effective way.

I’m not just talking about clinical skills, or therapeutic communication skills which are surprisingly important in my current position; I’m also talking about evidence-based practice, critical thinking, leadership, understanding hospital processes, effecting change, teaching and developing clear presentations and a whole pile of other stuff — a whack of skills I acquired along the way in my ED practice. The unfortunate fact is, the opportunities to develop and use all of these skill in front-line practice is limited. The fact I had to leave front-line practice to fully explore them is a telling, don’t you think?

Third lesson: Make the jump. I’m looking at all of you who think there must be more. Or better. Do something different. You won’t regret it.

Curiously enough a couple of days ago, someone named Darren Royds left this comment on one of my blog posts:

You need to get out and find a decent job. Have a life , live and reduce stress. I have quit nursing and was the best decision I ever made. You will end up as so many do.

Well exactly. I haven’t quit nursing, though. But as much as I loved working in the ED, it was clearly time to move on. It was the best job decision I have ever made.

Have you guys ever made a career change to/from/within nursing? Was the outcome good/bad/indifferent?

A few years ago I cared for an acquaintance. She was a friend of a friend who had been living out of the country for several years, but had come home to visit family friends. She was rushed in to the ED and before I even knew who she was I was delivering her 19 week old fetus. When I finally looked up to see the mother’s face I realized we knew each other. I said nothing. In that moment I didn’t care about what the College would say about caring for those you know when there was a real emergency to deal with. I held her hand as she passed the placenta and focused on stabilizing her blood pressure by putting in the largest IVs as I could. I asked her if she remembered me and if she would prefer another nurse cared for her. She asked me to stay. I comforted her and showed her the baby she would never get to know. I checked on her every half hour that shift and came in early for my next shift to find out how she was. There was no time to feel sad until my shift was over and like the other children and babies and fetuses I have seen pass away, they stick around in my heart and mind a lot longer. There are those patients that stick with you, elderly or middle aged, etc, but I think most any emergency nurse can agree that child patients are the some of the longest lasting in our memories. And for me, the ones who haven’t even started in this world are forever imprinted.

I saw my acquaintance a few months later, she was home again, in the grocery store and she thanked me for what I had done for her and told me she would never forget me. The thank you warmed my heart but I knew she would no longer remember me as the girl she had a beer with when we were in our early 20s, but as the nurse who was there when she lost her baby. Judgment, confidentiality, privacy, all of those ethical principles aside, perhaps that’s why we shouldn’t care for ones we know, even if just a little, because it affects us too.

I recently found out that she gave birth to a daughter and it’s amazing how happy I felt for someone I don’t really know to have had a baby. I wanted to find a way to contact her to wish her well but elected not to as I didn’t want to be THAT nurse wishing her well, inadvertently reminding her of what she lost before. Nevertheless, I personally take solace in knowing that despite all of the sad and terrible we see rarely hearing from these patients again, they do in fact have happiness and joy in their lives later on.

Abscesses and wounds, and especially abscesses and wounds which are infected, suppurative, purulent, and generally awful, are embarrassing for patients and difficult for nurses. Embarrassing for patients because they are disfiguring and smell badly, and difficult for nurses for really the same reasons. Personally I don’t mind caring for and treating wounds and abscesses, but I know plenty of nurses who would rather throw live kittens on a hot barbecue than go anywhere near a draining carbuncle.

Well, we are likely the healthcare providers who will first notice the problem. It will be during a dressing change, or just when you enter the patient’s room—you know. The scientific side of nursing will to clean the wound, inspect it, chart it, and if it is bad enough, inform the wound care team or physician. But remember, I said you are likely the first healthcare provider to notice. Trust me, the patient already knows.

This is where the nurturing side, the compassionate side of nursing is brought into play. And, it’s not for the weak of stomach or, particularly, the weak of heart. Bad smells carry a social stigma along with the health hazards inherent in the wound itself. Wet, sticky, bandages are a sign for all to see that there is a problem. People with wounds in this state often suffer inhibited work, social, and sex lives and frequently have feelings of shame and depression.

[SNIP]

You learn little tricks to help you not react (breath through your mouth, use a minty lip balm). Keeping the patient engaged is the key. Many of them won’t look at their wounds, won’t acknowledge there is a problem, or want to discuss it. You can teach them how to clean and dress their wounds, give them pamphlets and supplies, and help them plan future appointments but it is the emotional part of nursing that will often make the biggest impact on their healing and wellness.

Something we (remember?) were all taught in nursing school was the holistic care of the patient, that is, caring not only for the physical complaint of the patient, but also for the emotional, spiritual, social and even economic needs of the patient. Good wound care exemplifies nursing care in a microcosm. So when nurses see a patient with a decubitus ulcer, what do they see, the wound or the patient? Our inclination, of course, is to see the wound, somehow detached from the person bearing it, a way of thinking exacerbated by seeing nursing as a series of tasks to be completed rather than a holistic process involving critical thinking. Olin’s article, in this context, is a good reminder that in the end, we should be treating the patient, not the disease.

I recently took a course with nurses of varied years of experience and ages, but it was primarily made up of fairly new graduate nurses within the last year or two. During one lecture the facilitator was speaking about the future of nursing and how we need to address the current issues and challenges that exist in the nursing profession today, and asked the class to outline a few. Issues such as the global nursing shortage, heavier workloads, lack of education support, feelings of little public appreciation and individual unit situations were brought up. One nurse felt that on his unit there was a large divide between the older senior nurses and the new junior staff. This perked up my ears. He felt that the senior nurses were threatened by the amount of theory and knowledge that he and his fellow junior colleagues had and insinuated the senior nurses felt the juniors were going to take their jobs or roles on their unit. He continued to say that the generational and differing nursing requirement (degree vs. diploma) issues existing on his unit put a huge divide between the younger and older staff. (*disclaimer* While yes, I have written about how nurses can eat their young, I disagreed with the standpoint he took.) It’s terrible to think this is happening, and despite what I have written (that is only a handful of nurses FYI, by no means the picture of the entire Acme Regional ED senior staff in the least) I personally find that there is a great blend of ages and levels of experience within my unit personally. He stated that perhaps the junior nurses should be on their own line with the senior nurses on another. I cringed at the thought of that. For any unit to run effectively and safely it is in my opinion, which I am almost positive would be shared with most, that there needs to be senior staff at all times. A line of strictly junior staff would be unsafe and potentially detrimental to patient care not to mention the amount of issues, disagreements and incidents that could and would arise. I think of inconsistencies in care and the potential for a patient’s change in condition to be overlooked simply due to inexperience until too late. I have found that the novice and senior staff continue to learn from each other as each are on different ends of their careers with different types of knowledge to share. This nurse went on to say that maybe the senior staff needs to go in for remedial courses to be brought up to the “standard” of the new grad degree nurses. *insert shocked look on face*. I nearly fell off my chair. If the experienced diploma nurse does not want to go for their degree how and why could one be forced to take theoretical courses that in my mind, often have little to no benefit to the patient at the bedside. I relayed my personal opinion that the diploma nurses he is suggesting should go for remedial courses to be “brought up to speed” in fact had far more clinical time as students than any of us degree nurses and as a result were far better prepared going to the bedside when they graduated as opposed to us. I reminded him of the amount of papers and classroom time we spent talking more about nursing than actually doing it. I could write a 10 page paper on how to properly sew an emblem on a jacket with 4-5 APA references if I was asked to (please no one ask me) as a result of the amount of theory referencing involved in the degree program. This nurse’s sentiments about how degree nurses are far more qualified to be at the bedside than the diploma nurses and generation gaps exist out of jealousy or by being ill prepared made me question what sort of nonsense he was spoon-fed upon his obviously very successful graduation from a degree program. I am the product of the degree program but I do not endorse the structure of degree nursing program, at least not the one I was in. I think I should have been at the bedside far more than I was. I had yet to give an IM injection to a real patient until I was consolidating in my final 4th year placement. I had however written an excellent 25 page paper on nursing leadership and how to effectively determine who should get Christmas vacation with examples of different leadership skills, roles and suggestions on effective management.. *insert vomit sound*. I suppose however it can depend on what one wishes to do with their career and the direction they want to take it.

Ultimately what I am trying to get at is while I am sure generation gaps exist on units, I do not believe it is entirely as a result of degree vs diploma more than it might be just personality related. Differing maturity levels, different interests, and people at different points in their lives not to mention the obvious that we are all individuals. I enjoy working with the tough take no nonsense 15 year nurse as much as I like working with the 35 year veteran nurse who still gives every patient a bed bath and the novice 2 year nurse who wants to learn about every patient condition possible. A few of my closest coworkers have nearly 10+ years on me with a couple who could even be my parent.

Gaps exist only if we let them and really, we are not here to make friends. When we do that’s great, however, we have a job to do. If that 25 year nurse doesn’t like me, she at least knows I can get an IV on a 5 day old on the first poke and that’s all that matters. We often forget how our “issues” can affect the patients.

So i ask this, do generation gaps exist on your units? If so, are they related to degree vs diploma nurses or more just due to differing personalities and individuals at different points in their lives? Do you find yourself getting along with the nurses of the “opposite” generation?

If the newer generations of nurses out there are more confused than ever about their roles in healthcare — they should be. I’m one of the newer generations of nurses and I — AM — CONFUSED. Seriously. Think about it. We are taught all of the idyllic, pretty things every good and prudent

Navy nurses attending to a patient, 1960s. (Photo credit: Wikipedia)

nurse should know and should do whilst caring for patients. The Nurses Code of Ethics is drilled into our heads during nursing school, nursing care plans are celebrated (by our professors of course), and we are championed as the “future” and “promise” of nursing. The beautiful glowing white walls of academia ushers us out of the proverbial nursing nest with a maternal pat on the head, a gentle push, and into the place were supposed to actually do all the stuff were taught and licensed to do, and be who they taught us to be.

You’ve all heard it, I’m sure. “Get out there and make a difference! Change the profession for the next generation! Be the example! Implement policy! Be advocates for your colleagues and your patients!” Ummmm. Yeah. Nurses should act as advocates for not just their patients but for their profession. That being said, let’s take a look at what threatens to unravel the foundational fabric of who we are as nurses and what we do that sets us apart from all other healthcare disciplines.

1. Corporate Nursing. “We know what nursing is and what nurses do.” However, the moment you walk into the doors of any hospital, the nurse — the persona, and everything else — is redefined according to the wants and expectations and interests of the organization we work for. Nursing, as a discipline, as a science, is redefined. You are who your employer wants and expects you to be. Period. Your own nursing style or “way” of nursing? Leave it at the door, and step into the predefined mold thank you very much. Advanced education? Yeah, that’s great, but you aren’t actually supposed to use it. That MSN is supposed to look good after your name on the plaque that lists all the Masters prepared nurses on the unit you work within. A point of pride that all patients are supposed to gawk at and be impressed by when they walk into the entry way of the nursing unit. I tried using it; I tried to contribute—nope. We just want the letters from you, that’s all.

2. Teeny, tiny amount of autonomy. I mean, come on people. We still have to get orders to ambulate our patients two to three times daily after surgery, to get an incentive spirometer, to initiate pre and post-op teaching, and even to monitor ins and outs every four hours. Every state has a different nurse practice act, and there is no set regulation as to what nurses can and cannot do across the United States. Every state defines Nurses and their practice and what they can do differently. Take a group of 5 doctors—and chances are each one of them don’t even have a good understanding of what nurses are and what they do and their role. Interdisciplinary Models of Care are not the standard yet, so this inhibits a productive and working knowledge of what each provider does.

3. Disregard for Care Plans. This is a big one for me. I recently read a couple of articles that, for the most part, said care plans should just die and go by the wayside because they are useless.

4. A fractured profession. We have so many specialties that we still have failed to come together in a unified manner to advocate together for our profession and for the vital role we play in the lives of our patients, evidence based practice, theory development and application, and policy making. The result? Thousands of different visions from thousands of different nurses about what our profession “should be” and “should do.”

5. Silencing of our voices. We now have to choose between our own career survival, or own livelihoods, professional reputations, and paychecks—and speaking up in the best interests of our patients. Many a nurse has experienced this tragic conundrum, and the consequences are well documented if you log into your university libraries and do a good literature review on the topic. So, which will it be? Your pay check or your patient’s life? Well, now, that depends—can you like yourself when you go to sleep at night or when you wake up the next morning. The choice will be different for all of us.

6. Too many initiatives!!!! There are so many initiatives out there that it truly is like ‘herding cats’ to get everyone on the same page about what needs to bedone to improve, advance, and grow our profession.

What I feel needs to be done is simply this: get back to basics. All the initiatives are great. The pretty, flowery, shiny, idealistic profession they propose is in theory—just that. It seems like every time we turn around there is another nursing initiative being introduced. In fact, there are so many, we all seem to have thrown up our stethoscopes in exasperation while uttering “Whatever.” The RWJF, the NIH, AACN, the National League for Nursing, Johnson and Johnson, the Institute of Medicine and all the other organizations that produce the massive documents proposing their positions on where nursing should be by the year “such and such” need to set aside “Candyland” and get back to the drawing board.

How? Perform a learning assessment and care plan on the profession. TALK TO THE NURSES AT THE BEDSIDE—these are the stakeholders that have to carry out all the grandiose changes. ASK nurses what would motivate them to carry out change and what they need or want to learn to carry out the change. Perform a force field analysis to illustrate whether there is a greater push for or against change and where a balance can be achieved to promote success. What do nurses consider an incentive to participate in the change process? What is their currency?

Here is a good example of what happens when big organizations try to make even bigger changes sans discussion with their staff members, which is to say, their stakeholders. At one hospital I worked at the Transforming Care At The Bedside Initiative was being “enforced” as a means to improve patient satisfaction scores. I say the word “enforced” because we nurses weren’t asked about how we felt about it, we weren’t “completely” educated about what TCAB was, why we should be interested in it, or why we should participate in it. participation was an expectation and people were “assigned” to do parts of the initiative. No communication took place between management and staff about how they felt about the change process or the new “tests of change” they were being expected to participate in. So, it was not a big surprise to see my coworkers increasingly annoyed when they were being presented with “more steps” in their workday, or “more papers” to fill out or “scripts” taped to their computer monitors directing what they were to say to their patients. It was also not surprising to see that few or no staff members were attending the TCAB meetings to provide input and feedback.

Having gotten my Masters Degree I quickly realized what was missing was a well-planned approach to the change process. A crucial step within the change process is involving every person that could possibly be involved in that change: polling people, studying your stakeholders and what their motivations are, illustrating what is ‘in it for them’ should they take part. Failing to study all of your stakeholders and ask for feedback prior to initiating change is simply wasting a lot of time and yelling through a megaphone at an empty nursing station. I did some further research into the TCAB Initiative by immersing myself in the RWJF website for a couple of weeks.

After doing so, I discovered that our organization was not implementing TCAB as it was meant to be implemented. The organization was taking bits and pieces of the initiative and implementing them. The focus of the initiative — promoting happy nurses to promote happy satisfied patients — was not the managerial focus, as it should have been. It was strictly designed for patients, completely overstepping the spirit of the TCAB initiative as it was meant to be implemented. Lastly, the TCAB initiative was designed to be an interdisciplinary effort. The way it was being pushed at the organization I was at, the focus was just on nurses. I put together a white paper and power point and submitted them to my manager hoping it would help to get the project on track. I was promptly shut down with an annoyed response that my work looked plagiarized. (This is what an MSN on a nursing floor gets you)

So, managers, here are some lessons learned. If you want to make change on a large scale you must invest the time, no matter how long or how involved the effort, to study the people who have to carry out the work. Find out their goals, wishes, motivations, concerns, what makes them happy, angry, and frustrated. Find out what their knowledge base is and what must be learned to carry out the major initiative. Ask for their input. Discover who your “downers” are, why they are resistant to change, and how can you get them on board. It’s called “buy in.”

Lastly, harvest your talent. Take a fresh look at who your voices and cheerleaders are on the unit and give them “room to bloom where they are planted.” This is how and where you become a transformational leader instead of a leader who suppresses the creativity and potential of your nursing staff. One note: if you are going to implement something huge like the RWJF TCAB Initiative, don’t just take pieces of it and throw together your own version and expect it to work.

(Photo credit: Wikipedia)

This, in my opinion, is what all of the large nursing organizations who want to transform healthcare need to do. Round everybody up for a week-long conference, every stakeholder — not just administration and management figures or politicians either. The real people: the bedside nurses, pharmacists, lab workers, patients, doctors, PA’s, housekeepers and so on. Paint the closest picture you can get to a collective vision everyone seems to share. Then, figure out how to get there, one step at a time.

All the big goals are great.I love the visions of where the RWJF and the IOM and the AACN see our profession, healthcare, and nursing education headed. But the visions are a problem too. There are too many ideas, initiatives, and too many people “other than bedside nurses” generating them. Our profession is fractured enough. It is not feasible, nor is it realistic, to expect every wonderful idea and vision to be carried to fruition when there is currently a longstanding lack of unity and disarray within nursing.

So, for the time being, let’s set aside the huge mountain of ideas and initiatives and take a deep breath. Now, start over with the A-B-C’s: Airway, Breathing, Circulation. Set the sights on resuscitating the profession of nursing first, before we attempt to heal the ailing healthcare system and the world. Take it back to the old school, and do the assessment first. Then, make a plan: implement it, evaluate it, and do it all over again until we get nursing back on track with a unified focus. Only THEN can we climb the mountains set in front of us by the RWJF or the IOM or the NIH. We cannot build castles without a strong foundation of earth below it.

By the way . . . Did anyone notice how often I used the word “initiative?”

__________Amanda blogs at NurseInterupted. This is a slightly modified version of a post which originally appeared on her blog.

A very good, if obvious, idea on the use of RNs: nurses should be used to the full extent of their abilities. From the Toronto Star (and kudos to the paper for their Nursing Week insert in Saturday’s edition):

“The bottom line is that we’re wasting valuable resources with our RNs,” says Doris Grinspun, the Registered Nurses’ Association of Ontario’s chief executive officer. “European countries like the U.K. have been using RNs to their full capacity for years. It will be a missed opportunity for the public, taxpayers and patients if we don’t move to full utilization of our nurses.”

[SNIP]

[Grinspun] wants the province to recognize the education and expertise of registered nurses, and to agree that they could be doing more within the scope of their practice, like diagnosing patients, ordering diagnostic and lab tests, conducting pelvic exams and prescribing medications.

Though the mandate of Ontario’s action plan for health care is to find ways to maximize the system, full utilization of care providers isn’t possible until the government revamps policies about who can bill for certain medical procedures. “We should be using nurses and all health-care providers to open access, increase the timeliness and quality of care and to contain cost,” she says. “But if a nurse does a pap smear, the doctor doesn’t get paid. If a nurse diagnoses a child’s ear infection and prescribes antibiotics, the physician doesn’t get paid. I go berserk when I see doctors taking blood pressure,” she says. “Nurses have the training to free up a doctor’s time in primary-care settings so she can focus on more complex situations.” Plus, the move to grant registered nurses more autonomy on the job would lower the waiting times for patients to be seen, meaning there will be fewer patients showing up at walk-in clinics and emergency rooms.

Not exceeding their scope of practice

The (somewhat) amusing thing about this idea is that nurses (or least those working in in high acuity areas like ICUs or Emergency Departments) already do all much of this in an highly unsanctioned, unregulated and unofficial way. Let me provide a simple example. Suppose I am triaging an exceedingly anxious patient with chest pain, and decide the patient requires an ECG — which incidentally I can order under medical directives. I explain the test to the patient. I tell her ECGs measure the pattern of electrical activity in the heart and therefore can show dysfunction. I place the electrodes across her chest and limbs, and carry out the test. The printout shows a patient in a regular sinus rhythm with no acute abnormalities.

Do I tell my agitated patient, whose anxiety is growing by the second, that (A) the ECG shows her heart is performing in a normal way and that we need to do some blood tests to confirm everything is okay, or (B) that the physician will discuss with her the results of the ECG when he sees her — which might be in a couple of hours?

When I was a new nurse, some years ago and being a good, diligent practitioner, I would have told this patient (B). This was not to dog my responsibilities or pass off work to the physician. (B), in fact, is the correct answer. Interpreting a test for a patient is considered a form of diagnosis, and in Ontario and most jurisdictions, making and communicating a diagnosis is considered the exclusive preserve of nurse practitioners and physicians.

But this is the deal. I have been educated how to interpret ECGs. I know how to tell atrial fibrillation from SVT from sinus tachycardia. I know what ischemia looks like, and I can spot ST elevations in a steam bath. More importantly I have the judgement to recognize the borderline cases and defer to the physician. Additionally, it seems to me, cruelty, indifference and bad nursing can be defined by a nurse telling a patient — especially one that is anxious — that she needs to wait to speak to the physician about her ECG because of “the rules.”*

I am not for stupidity in the form of thoughtless adherence to regulation. I am not for cruelty either. So I decided a long time ago, that on balance, it was altogether better for the patient to have this information, rather than sit in the waiting room in a state of high anxiety. Even if my professional regulatory body has officially determined I can’t because technically it is beyond my scope of practice.

And so it goes. Nurses quietly and unofficially violate the scope of practice all the time. We push the envelope. We add blood work we think the physicians have missed. We slip in chest films because we know they need to be done. We order ECGs on patients we don’t like the look of. We review lab results with patients. We cajole specialists into “having a peek” at a patient if we are worried about them. We tell patients — sometimes in very circular language, to avoid the damning “communicating a diagnosis” — what really is going on.

Why do we do it? Sometimes we know physicians will support us. Sometimes it’s to avoid difficult conversations with physicians, or because physicians won’t listen to the opinion of a mere nurse. (One physician I know of absolutely refuses to order serum lactates on obviously septic patients, because a positive result means she needs to follow a complicated sepsis protocol — even though the literature is pretty clear that early and aggressive intervention in sepsis saves lives.) Bottom line: we do it in the interests of the patient.

Should nurses be permitted to utilize their full knowledge and skills? Absolutely. It’s better for patient care and better for nursing work life. And also we need to formally regulate what nurses do already, to protect nurses themselves.

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*The College of Nurses of Ontario, my professional regulatory body, would probably, and unrealistically suggest the alternative of getting the physician to speak to the patient immediately after doing the ECG as the “proper” course of action. But think about it this way: my ED probably does 30 ECGs (if not more) in the course of a 12-hour shift; if it takes a physician 5 minutes to discuss the results with a patient, then 30 x 5 minutes = 150 minutes = 2.5 hours. That’s a pretty big chunk of time, and in a busy department, is not going to happen. And that’s if you could get the physician to come out to triage to see the patients to begin with. It is simply not good use of his time and is completely unnecessary. Which rather demonstrates the point of the article quoted above.

An underexplored or ignored aspect of nursing professional life: how nurses working in a Labour and Delivery unit grieve over the loss of their patients, and how this grief affects care and support of survivors. What is really striking about the film is the culture of mutual support and respect among the nurses working in this unit — I hope it’s real and not just the product of the filmmaker’s eye, but the cynical side of me wants to think it’s idealized.

Though the film’s focus is in L & D, it makes me think of how nurses deal with loss in the Emergency department. The prevailing culture and mores of most EDs does not encourage touchy-feely moments, at least in not many of them. The expectation, frankly, is to suck it up and tough it out. The Emergency department is not for the weak of heart. Shrinking violets need not apply. Et cetera. But the question is whether we as nurses are able to provide good care to our patients without acknowledging and reflecting on how grief affects us. Or whether unacknowledged and unvalidated grief leads to higher burnout — and also some unintended psychological effects like PSTD.